- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $34.67 / $34.67 / $2,187.76
| Facility | | $34.67 | $34.67 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $34.67 / $47.86 / $2,884.03
| Professional | | $34.67 | $47.86 | $2,884.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,862.09 / $2,951.21
| Professional | | $1,288.25 | $1,862.09 | $2,951.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $58.88 / $58.88 / $58.88
| Facility | | $58.88 | $58.88 | $58.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $44.67 / $77.62 / $144.54
| Professional | | $44.67 | $77.62 | $144.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $39.81 / $69.18 / $104.71
| Professional | | $39.81 | $69.18 | $104.71 |